Can Medbill help if we are already facing an audit?

Yes. Our compliance team provides audit support services, helping you gather required documentation, respond to payer requests, and minimize financial risk.

How do I prepare for an audit?

Our team can help prepare your business for upcoming audits, but if you choose to go it alone:Review your claims process for gapsAnalyze denied claims for trendsConduct internal audits to identify missing informationMake process improvements based on findings

How long must records be kept?

Providers must retain documentation for seven years from the date of service.

How will Medbill’s documentation services improve our revenue cycle?

Accurate documentation reduces claim denials and delays, which means faster reimbursements and healthier cash flow. By ensuring records meet payer requirements, we help providers strengthen their revenue cycle management (RCM).

Is a CMN enough for reimbursement?

Not by itself. While a Certificate of Medical Necessity (CMN) is an important document, payers typically require additional supporting records, such as the physician’s notes, Standard Written Orders (SWOs), and Proof of Delivery (POD). Together, these documents establish medical necessity and strengthen your claim for reimbursement.

We supply a wide range of DME products. Do you have expertise across different product categories?

Yes. Medbill’s team works with DME providers across a broad range of product categories, including respiratory, mobility, wound care, and more. Our billing expertise extends across multiple payers and product lines.

What documentation is needed for Medicare DME claims?

It varies by product and payer, but typically includes:Patient’s medical historyPhysical exam resultsDiagnostic test findingsDiagnoses and treatment plan

Can Medbill help if we are already facing an audit?

Yes. Our compliance team provides audit support services, helping you gather required documentation, respond to payer requests, and minimize financial risk.

How do I prepare for an audit?

Our team can help prepare your business for upcoming audits, but if you choose to go it alone: Review your claims process for gaps Analyze denied claims for trends Conduct internal audits to identify missing information Make process improvements based on findings

How long must records be kept?

Providers must retain documentation for seven years from the date of service.

How will Medbill’s documentation services improve our revenue cycle?

Accurate documentation reduces claim denials and delays, which means faster reimbursements and healthier cash flow. By ensuring records meet payer requirements, we help providers strengthen their revenue cycle management (RCM).

Is a CMN enough for reimbursement?

Not by itself. While a Certificate of Medical Necessity (CMN) is an important document, payers typically require additional supporting records, such as the physician’s notes, Standard Written Orders (SWOs), and Proof of Delivery (POD). Together, these documents establish medical necessity and strengthen your claim for reimbursement.

We supply a wide range of DME products. Do you have expertise across different product categories?

Yes. Medbill’s team works with DME providers across a broad range of product categories, including respiratory, mobility, wound care, and more. Our billing expertise extends across multiple payers and product lines.

What documentation is needed for Medicare DME claims?

It varies by product and payer, but typically includes: Patient’s medical history Physical exam results Diagnostic test findings Diagnoses and treatment plan

Young woman holding claim documents checking information in office

DME Documentation Requirements for Providers

Submitting accurate documentation is one of the most important steps in getting DME claims approved (and keeping those reimbursements if you’re audited). With Medicare and commercial payors closely monitoring claims, providers need to stay on top of documentation requirements to avoid delays, denials, or take-backs.

At Medbill, we work alongside DME providers every day to ensure documentation—such as Standard Written Orders (SWOs), Proof of Delivery (POD), and physician records—clearly supports medical necessity and aligns with payer requirements.

Our documentation experts help providers eliminate guesswork and meet every payer’s expectations before claims go out the door.

Why DME Documentation Matters

Documentation creates the necessary paper trail that justifies a patient’s need for equipment or supplies. Each claim must include supporting documents, such as prescriptions, clinical notes, and prior authorizations, that clearly show medical necessity.

When your documentation is complete and accurate, you:

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Speed up claim approvals

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Reduce the risk of denials

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Stay prepared for audits

Key Documents for DME Claims

Accurate documentation is essential for clean claim submission and faster reimbursements. Some of the most critical forms DME providers must maintain include:

Standard Written Order (SWO): A signed order from the prescribing physician that details the specific DME item, quantity, and usage instructions. An SWO is required before billing Medicare and most commercial payers.
Proof of Delivery (POD): Documentation that verifies the patient received the prescribed equipment. POD helps demonstrate compliance and is often required during audits.
Certificate of Medical Necessity (CMN): A form completed and signed by the prescribing physician that explains why the DME item is medically necessary for the patient’s condition.
Prior Authorization and Medical Records: Supporting paperwork showing payer approval and clinical evidence of medical necessity.

Documentation and Audits

Audits are designed to confirm that DME claims are supported by medical necessity. Different types of audits target different aspects of documentation, including:

Comprehensive Error Rate Testing (CERT)
Medicare Administrative Contractor (MAC) audits
Recovery Audit Contractor (RAC) reviews
Unified Program Integrity Contractor (UPIC) audits

A strong document management system makes audits far less stressful. These systems let you organize, track, and access patient records quickly—so you’re always audit-ready.

Physician Documentation Requirements

Physician documentation is central to DME claims.

Submissions should include:

Prognosis and medical history
Expected benefit and outcome of the DME item
Clinical and functional status supporting medical necessity
Provider’s treatment plan
Certificate of Medical Necessity (CMN)

The patient’s medical record is especially critical. It should show why the DME is needed, how often it will be used or replaced, and how it supports the provider’s treatment plan.

Avoiding Documentation Errors

Even experienced DME providers lose revenue to preventable documentation mistakes.

Here are the most common mistakes:

Missing coverage, coding, or billing details
Failure to include the physician’s NPI on written orders
Orders from physicians not actively enrolled in Medicare
Missing documentation that wasn’t required at submission, but is required in an audit
Taking time to review your files and learn from denied claims can prevent costly mistakes

Documentation Checklists: Tools to Help You Stay Compliant

CMS and the DME MACs provide checklists to help providers stay organized. Each one outlines the exact documents required for different categories of DMEPOS.

Download Noridian Healthcare’s General Documentation Requirement Checklist (Jurisdiction D), or view other DMEPOS category-specific checklists.

Using these tools will help streamline your billing process and protect your reimbursements in the event of an audit.

dme training with instructor overseeing 2 employees and their computer screens

Partner with Medbill:

Turn Documentation Requirements into Reimbursement Success

Keeping up with ever-evolving documentation requirements can be overwhelming. Let us help bring clarity to a complicated process.

With over 20 years of experience in the DME industry, you can trust our team to:

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Stay current on CMS and payer updates

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Identify gaps in your processes before they become denials

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Train your staff on efficient, compliant billing practices

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Provide support that helps you stay audit-ready

Partnering with Medbill for billing and documentation support allows your team to focus on patient care. We’ll help you maximize reimbursements and build a stronger, more efficient revenue cycle.

Because we work with both independent DMEs and national suppliers, we understand the documentation nuances across every major payer and product category.

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FAQs About DME Documentation

Quick answers to the documentation questions that matter most for your billing success.